Physiatry Practice Management Resources

The author has treated more than his share of these challenging individuals. Here are some valuable tips he's learned that will make your job easier. Ferrell was a difficult patient. I took a deep breath as I entered her room. She'd been admitted for abdominal pain and vomiting, but the workup over the past two days had been negative. By now, I doubted there was any point in keeping her in the hospital. But I knew she would resist leaving. Her history was littered with ED visits for similar complaints. She had even been admitted a month ago for the same complaint; the workup had been negative then, too.

Although I realized that her workup was reaching an end, I employed the strategy I use with all my difficult patients: I continued to acknowledge her problems. When the final test—a small bowel X-ray—was negative, I offered Ms. Ferrell her discharge. She wanted a dermatologist to look at the skin lesions that I couldn't see. My response: a smile. "No," I said, "but I can certainly get you the name of an excellent dermatologist. It's not easy to get one to come to the hospital for something that can be dealt with in the office."

I had no evidence that Ms. Ferrell was malingering; she probably had a somatization disorder. By this time, I had talked to the social worker who detailed utter chaos in the patient's personal life. Apparently, her last admission had come on the heels of an acute problem at home. This admission seemed to be following the same pattern.

I sent her home with recommendations to see her primary doctor and to seek a chronic pain specialist.

Difficult patients are difficult not because they're a medical mystery, but because they challenge our psychic defenses, stretch our tolerance and patience, or demand much more of our time than we can give. But it is possible to care for these challenging patients—if you know how. Here are the five rules I've developed:

RULE 1

Know yourself. Taking on a difficult patient can spiral into a battle of wills and wits that you're destined to lose. That's why it's necessary to understand your own limitations and personality. You have to manage your emotions: Be as professional and calm as possible, regardless of what your patient says or does.

This isn't to suggest that emotion is bad; it's necessary to care for the human being in front of you and to create a therapeutic relationship. But you need to avoid emotion that clouds your judgment and over-personalizes your interaction with the patient. This takes practice and a willingness to learn from mistakes.

RULE 2

Know the patient. Knowing the medical and psychiatric history of the patient is the bare minimum. You have to understand the patient's past patterns of behavior in order to ascertain future behavior.

Most difficult patients fit one or more of the following personality types:

• someone with underlying personality disorders that lead to noncompliance or to self-destructive behavior like alcohol or drug abuse
• a malingerer who's seeking narcotics or some form of secondary gain in the form of increased attention from family or medical personnel
• someone with a somatization disorder ranging from the one-time chest pain admission to the chronic headache patient who visits the ED every month

These complaints need to be addressed head-on once organic conditions have been ruled out. Multiple ED visits for headache, chest pain, or abdominal pain may signal an underlying psychosocial problem that can be best addressed with the help of a psychiatric professional or chronic pain specialist.

Titus Abraham, MD
Medical Economics Magazine